Re “There’s no place for politicians in the medical exam rooms of the nation” (July 7): Katharine Smart condemns Alberta’s proposed restrictions on puberty blockers, hormone therapy, and “top surgery” for minors. She argues with the Canadian Medical Association that minors, like other patients, should be allowed “to make the best decisions for their own health,” and asserts that such treatments help young people “thrive.”
Smart does not address the arguments of any of the authoritative recent studies from countries such as Sweden, Denmark, Finland, Britain, and Australia that have concluded the opposite: that the potential harms to minors from such treatments outweigh the benefits. In its unquestioning acceptance of “gender affirming care” for minors, Canada is quickly becoming an outlier.
I’m neither a doctor nor a researcher, but I do know that ignoring the case your opponents have made does not make it go away.It’s a letter I’d like to expand on; I’ll do that now.
To be fair to Smart, her piece is an op ed column, not a full-length article; this is a hugely complicated issue, and she could not possibly have addressed everything that’s in dispute. But she could at least have acknowledged that a great deal is in dispute, and that numerous reputable medical associations and government authorities elsewhere in the world now take a stance that is very different from that taken by most Canadian and American medical associations.
None of the authorities elsewhere in the world, thank goodness, has adopted the anti-trans tone of hostility that is the norm among the many Republican lawmakers in the US, who aim to ban outright all these treatments for minors. On the whole, countries such as Sweden, Denmark, Finland, Britain, and Australia are taking a nuanced approach--but they are putting legal restrictions in place for patients younger than 18. Sweden, for example, restricts the use of both hormone treatments and puberty blockers for those younger than 18 to very rare circumstances, while banning transition-related surgery* before the age of 18; Britain allows hormone treatments for minors while banning puberty blockers and transition-related surgery before the age of 18. In short, authorities in these nations and others have been significantly restricting access to these treatments for minors. And in these and many other countries, there continues to be a lively debate as to the benefits and/or harms of these treatments.
In their unquestioning acceptance of “gender affirming care” for minors, then, Canadian and American medical associations do indeed seem increasingly to be outliers.
It’s not only the treatments themselves that are under scrutiny; claims that teens are more likely to commit suicide if they are denied these treatments are also now widely disputed.
These studies come from accredited researchers; they’re not the product of anti-trans or anti-science zealots. Nor do the governments that have in recent years restricted such treatments for minors (in ways similar to those proposed by Alberta) in any way resemble the Trump administration, with its appalling willingness to allow anti-trans discrimination in employment, in military recruitment, and in other areas.
You don’t have to go to right-wing media outlets to find out about this research; it’s been widely reported on in centrist or center-left media outlets such as The Globe and Mail, The Atlantic, The Economist, The Washington Post, and The New York Times.**
Strikingly, various organizations that unquestioningly support providing these treatments to minors have focused their attacks not on Republican lawmakers or on Fox News and other right-wing media outlets that have clearly provided biased coverage, but rather on The New York Times. GLAAD.org, for example, has run advertisements calling on the Times to “stop questioning trans people’s right to exist and access to medical care.” As you might expect, The New York Times has in fact never questioned trans people’s right to exist, and nor, except where children and teenagers are concerned, has it ever published anything suggesting that trans people should ever be denied any of these treatments. Indeed, the Times has been an outspoken defender of transgender Americans (see, for example, the Feb 9, 2025 lead editorial, “Trump’s Shameful Campaign Against Transgender Americans”). And the Times, it should be added, has also given a considerable amount of space to those who argue that minors’ access to treatments such as hormone therapy, puberty blockers, and transition-related surgery should not be restricted by any laws. (See, for example, Lydia Polgreen’s extended article criticizing Britain’s Cass Report, published in the Times under the headline, “The Strange Report Fueling the War on Trans Kids” [August 13, 2024].)***
Organizations such as GLAAD seem eager to paint anyone who does not share their position 100% as transphobic; the insults and misrepresentations at the other extreme are even worse. Republican Senator Roger Marshall of Kansas, for example, has introduced in Congress a bill titled the “Safeguarding the Overall Protection (STOP) of Minors Act.” Couched in incendiary language (“castration procedures,” “gender mutilation procedures”), it would prohibit all forms of youth gender transition treatment at any stage. Such treatments, Marshall claims, are part of “the Left’s dangerous transgender agenda. Let’s call it exactly what it is: child abuse.”
Let’s set that sort of hysteria to one side and return to the arguments made by Katharine Smart. There are three of these. The first is an appeal to authority; she cites various associations in North America that support such practices. But one can appeal to other associations and other authorities; neither Sweden nor Britain allows transition-related surgery to be performed on patients under the age of 18. Are the North American medical associations right about this, or are Sweden and Britain right? Again, I just don’t know. Smart and the Canadian Medical Association may well be right. But I certainly think it’s possible that Sweden and Britain are right—and that the policies Danielle Smith and her Alberta government have adopted on this issue in Bill 26 may eventually be acknowledged everywhere to make more sense than those recommended by the CMA.
Raising even the possibility that Danielle Smith and her government might eventually be acknowledged to have been right about anything may in itself seem objectionable to some readers. And I can understand that. I’ve disagreed with just about everything Danielle Smith has done and has stood for since she entered politics, from her gung-ho support of the oil and gas industry and her discriminatory policies against solar and wind energy to her recent move to remove books with sexual content from school libraries.
But I think it’s vitally important—at any time, but perhaps more than ever in times as polarized as our own—to be open to the possibility that people whose political orientation is entirely different from our own can sometimes make the right decision, or do the right thing. I disagreed with just about everything George W. Bush stood for when he was the American president, but I thought then and I think now that he deserves considerable credit for launching the Emergency Plan For AIDS Relief in 2003. I disagreed with just about everything Donald Trump stood for during his first term as American president, but I thought then and I think now that he deserves considerable credit for his Operation Warp Speed initiative to develop vaccines quickly in 2020.
I disagree as well with the rest of what’s included in the Smith government’s Bill 26 (the other provisions of which include giving parents a veto on whether or not their children receive sex education in school, and giving parents a veto on their 16- and 17-year-old children choosing their own pronouns in school). But when it comes to the bill’s provisions regarding hormone therapy, puberty blockers, and gender-transition-related surgery (provisions that would prohibit hormone therapy and puberty blockers for patients 15 and younger, and prohibit mastectomies and genital surgery for those under 18)--I’m just not sure. Given what I’ve read of the recent research and of the stances taken in countries such as Sweden and Britain, I think there’s at least a chance that the Alberta government--a government whose policies I detest in just about every other area--may have gotten it right in this one area. Certainly Katharine Smart’s argument from authority, citing only those associations that have approved all these “gender affirming treatments” for teenagers and ignoring those that haven’t, fails to convince.
What of Smart’s other arguments? One of these is an argument from personal experience. Smart speaks of how carefully she listens to her patients, and of how she prescribes hormone therapy or puberty blockers to "only a small minority" of her under 18 patients; she attests from her experiences with her own patients that, "for the youth who do receive" those treatments, it's often transformational." There's no reason to doubt any of this. But one can accept Smart's anecdotal evidence in its entirety and still have doubts as to whether the course she recommends is the best way forward. Even from this one column one can infer that she is an extraordinarily caring, sensitive, and conscientious physician. Reports from other quarters, though, have made clear that Smart's approach is not always followed by others; some teenagers have been put on hormone therapy or puberty blockers with barely any questioning having been conducted. And other reports have made clear that, for some, gender-transition treatments at an early age have not been "transformational"--or at least, not transformational in a positive way. Certainly the personal experience of one physician with her patients--no matter how positive--should not be taken as conclusive.
Smart's third argument is one of overarching principle; she argues that medical matters should be between “the doctor and their patient. Full stop.” She ends by warning of a slippery slope, suggesting that if the Alberta “precedent is left to stand, the care and treatment that you need may be next.”
But do we in fact as a society accept that all medical matters should be entirely left up to the doctor and the patient? For most medical matters, we do indeed accept it. But what of a Jehovah’s Witness teenager who is adamant that they do not want a blood transfusion? In Quebec in 2017, a court decided that a health center should be allowed to give a 14-year-old blood transfusions, against her own wishes; the judge ruled it lawful to protect patients against their own wishes when a decision had the potential to irreversibly alter the patient’s life. Many Jehovah’s Witnesses would I’m sure argue that, when psychological and spiritual health are taken into account, blood transfusions do not have any health benefit—and some doctors who are also Jehovah’s Witnesses would surely support that view. What of the practice of female circumcision (aka “female genital mutilation” or “female genital cutting”)? In Canada and in many other countries of the world we agree that the practice has no health benefits; many in Somalia, Egypt, and Saudi Arabia would I’m sure disagree—including many doctors and many young women.
I should make clear that I am not defending the Jehovah’s Witness view of blood transfusions or the horrific practice of female genital mutilation. I raise these examples merely to show that our society does not in fact accept that all medical matters “should be between the doctor and the patient. Full stop.”
Why are these issues so important? They’re important, first of all, because they affect the mental and physical health of a significant number of young people. It’s vitally important that we do everything we can to get it right when it comes to the question of what practices are likely to give those young people the greatest benefit and/or cause them the least harm. But it’s also important simply because it’s become such an inflammatory issue in so much of the world—and one that, rightly or wrongly, has become tightly entwined for many people with overall political and ideological orientation. The level of hostility—and the impulse to shut down reasoned debate—is staggering. On the left, it’s become common to label those who advocate any level of caution in gender therapy for minors as transphobic. On the extreme right, it’s worse; people such as Daily Wire host Michael Knowles call for the eradication of “transgenderism”: “For the good of society,” Knowles declared in 223, “transgenderism must be eradicated from public life entirely—the whole preposterous ideology, at every level.”
In such a climate, it’s understandable that many have become scared to voice an opinion—even an opinion as tentative as this sounds like an area in which more research needs to be done. Some conservatives have been scared of being condemned by the likes of Senator Marshall and Michael Knowles if they do not sound off viciously against trans rights generally. Not a few on the progressive left have been scared of being condemned by the likes of GLAAD.org if they raise questions as to the appropriateness of hormone therapy, puberty blockers, or surgery in the context of “gender affirming care” for minors.
Clearly these are difficult issues, and extraordinarily complicated ones; conducting the necessary research is fraught in all sorts of ways. But we need that research to be conducted—and lowering the temperature of public discourse will surely make it easier for that to happen. We need less heat, more light. Much as I may doubt her conclusions, Katharine Smart is clearly one who aims to bring light rather than heat to these controversies; this blog post is written in the same spirit.
*In rejecting Alberta's approach, Smart does not specifically mention transition-related surgery, though that is very much one of the foci of the Alberta legislation. Most defenders of unrestricted "gender affirming care" for minors have little to say about the practice of performing mastectomies on minors who want to transition, other than to say that the practice is very rare. Perhaps so; frustratingly, neither American nor Canadian official statistics are available. In the United States, the news agency Reuters conducted its own study several years ago and reported that in a three-year period, 2019–2021, 776 people younger than 18 had had mastectomies in connection with gender dysphoria. In Canada, the National Post reported in 2023 that over 300 Canadians under the age of 18 had undergone such treatment. No one knows the totals in 2025—but no one denies that such surgery has been legally unrestricted in most North American jurisdictions, and that it does continue to be performed on minors. Given that some at least who have transitioned as teenagers later come to regret their decision and want to detransition, and given that a double mastectomy is not reversible, it is hardly surprising that such surgery has become highly controversial.
**See, for example, these articles: Emily Bazelon, "The Battle Over Gender Therapy: More teenagers than ever are seeking transitions, but the medical community that treats them is deeply divided about why — and what to do to help them," The New York Times, March 17, 2023; Pamela Paul, “As Kids, They Thought They Were Trans. They No Longer Do,” The New York Times, Feb 22, 2024; Nicholas Confessore, How the Transgender Rights Movement Bet on the Supreme Court and Lost, The New York Times, June 19, 2025; Helen Lewis, “The Liberal Misinformation Bubble About Youth Gender Medicine: How the left ended up disbelieving the science,” The Atlantic, June 29, 2025; Robyn Urback, “Trans youth deserve better,” The Globe and Mail, April 26, 2024; “America should follow England’s lead on transgender care for kids,” The Economist, April 10, 2024; Alex Byrne, “I co-wrote the anonymous HHS report on pediatric gender medicine: The hostile reaction to our work shows why we needed to do it in the first place,” The Washington Post, June 26, 2025; “A landmark study of gender medicine is caught in an ethics row,” The Economist, 30 April, 2025.
***The Times also ran a selection of letters responding to the article ("The Cass Report: Biased or Balanced?", Sept. 1, 2024), and published over 800 comments on its website. To me, a letter from Gerald Ryan, of Madison, Wisconsin, was among the most persuasive. Let me quote from it here:
I am a retired physician who, as the medical director of a major university, instituted the provision of gender-affirming medications at our health facility, so I hold no bias against the appropriate use of these treatments. I found Dr. Hilary Cass’s report to be informative, well researched and balanced.I think many would be surprised to learn that the movement toward expanding gender-affirming medication for children is based largely upon a couple of small studies by researchers in the Netherlands that utilized strict inclusion criteria for their cohorts.Most current treatment guidelines on the use of these interventions stem from the collective opinion of experts in the field. This opinion alone, though helpful, is a shaky foundation for the initiation of sometimes irreversible procedures.Dr. Cass is simply stating that the science of gender-affirming care for children and adolescents is very much in its infancy and its usage requires thoughtful deliberation until we know enough to make conclusive recommendations.
**** Appallingly, anti-trans extremists such as Senator Marshall conflate surgery to address gender dysphoria with the practice of surgically suppressing female sexuality through surgery; they use the term “female genital mutilation” to refer to gender-identity-related breast and genital surgery.
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